We conclude that almost all patients in this series with Cushing's syndrome have a lesion on dynamic pituitary MRI, a rate much higher than the 50-60% rate reported for non-dynamic MRIs. The false positive rate of 16% in our group of Cushing's excluded patients is similar to the literature value of 10% seen in normal volunteers and is acceptable since MRI is not used solely as a determinant for the diagnosis. While a negative MRI will miss those patients with adrenal or ectopic Cushing's syndrome, those patients can usually be diagnosed by other testing. Thus this preliminary study implies that dynamic pituitary MRI adds valuable information to assist in the diagnosis of Cushing's syndrome and should be ordered as part of the initial workup.
Many Endocrinologists believe that a single determination of eucortisolism or a single demonstration of appropriate suppression to dexamethasone excluded Cushing's syndrome, except in what was previously thought to be the rare patient with episodic or periodic Cushing's syndrome. We hypothesize that episodic Cushing's syndrome is relatively common and a single test assessing hypercortisolism may not be sufficient to accurately rule out or diagnose Cushing's syndrome and retrospectively examined the number of normal and abnormal tests assessing hypercortisolism performed on multiple occasions in 66 patients found to have mild and/or episodic Cushing's syndrome compared to a similar group of 54 patients evaluated for, but determined not to have Cushing's syndrome. We found that 65 of the 66 patients with Cushing's syndrome had at least one normal test of cortisol status and most patients had several normal tests. The probability of having Cushing's syndrome when one test was negative was 92 % for 23:00 h salivary cortisol, 88 % for 24-h UFC, 86 % for 24-h 17OHS, and 54 % for nighttime plasma cortisol. These results demonstrated that episodic hypercortisolism is highly prevalent in subjects with mild Cushing's syndrome and no single test was effective in conclusively diagnosing or excluding the condition. Rather, the paradigm for the diagnosis should be a careful history and physical examination and in those patients in whom mild Cushing's syndrome/disease is strongly suspected, multiple tests assessing hypercortisolism should be performed on subsequent occasions, especially when the patient is experiencing signs and symptoms of short-term hypercortisolism.
ObjectiveRecent studies have suggested that female sexual dysfunction may be has high as 40% in the United States and yet very few studies have examined sexual dysfunction in Hispanic women. Our previous studies suggested that low testosterone levels may be associated with both subjective and objective sexual dysfunction in hypopituitary women. Are there differences in testosterone levels, subjective and objective measures of sexual function between Hispanic and non-Hispanic females?MethodSubjective sexual function was assessed by the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) on 15 Hispanic and 10 non-Hispanic women. Total testosterone levels were measured. Objective sexual function measurements were by duplex Doppler ultrasound to assess clitoral blood flow before and after sexual stimulation. Medoc's GenitoSensory Analyzer-3000 was used to assess quantitative somatosensory thresholds of vibratory sensation.ResultsHispanic women did have a larger BMI that was statistically significant (29.05 ± 4.32 vs 24.30 ± 4.86, p = .0115). Hispanic women did have lower total testosterone levels but the results were not statistically significant (24.02 ± 1.25 ng/dL vs 37.75 ± 24.76 ng/dL, p = .3487). The Female Sexual Function Index (FSFI) suggested no statistically significant differences between Hispanic and non-Hispanic women scores on desire, satisfaction, orgasm, arousal, lubrication, and pain. On the Female Sexual Distress Scale, Hispanic women had more personal sexual distress than non-Hispanic women as suggested by a higher score (5.33 ± 6.66 vs 0.50 ± 1.22); however, these results were not statistically significant (p = .0952). On the objective tests, Hispanic women had less vaginal sensitivity than non-Hispanic patients as suggested by measurements of vaginal vibratory thresholds (4.25 ± 1.66 vs 2.03 ± 0.88 microns) that were statistically significant (p = .04); a higher number suggests less sensitivity. Hispanic women had greater changes in clitoral blood flow after sexual stimulation (38.88 ± 17.83 cm/sec vs 18.96 ± 9.36 cm/sec); however, these results were not statistically significant (p = .0727).ConclusionsThere were statistically significant differences between Hispanic and non-Hispanic women in BMI and vaginal vibratory sensations. Hispanic women experienced more personal sexual distress, had lower total testosterone levels, and had greater changes in clitoral blood flow after sexual stimulation.
Objective: The role of testosterone in cognitive and psychological function in women remains poorly understood. Women with hypopituitarism have severely diminished ovarian and adrenal androgen production and thus represent an excellent model to study the consequences of androgen deficiency. We hypothesized that women with hypopituitarism would exhibit altered psychological function and decreased quality of life as a result of androgen deficiency. Method: Total testosterone, cognitive function and quality of life questionnaires (POMS, NHP Questionnaire, Fatigue Impact Scale, SCL-90-R) were obtained from 15 women with documented hypopituitarism (median age 37.5±7.1, BMI 28.1±5.2) and 9 aged-matched healthy volunteers (median age 26±9.2, BMI 25.6±4.2) in an IRB-approved study. Results: Total testosterone levels were markedly diminished among women with hypopituitarism (4.7±3.9 ng/dL) compared to normal volunteers (25.5±2.7 ng/dL, p≤0.0005). All cognitive function and quality of life questionnaires (POMS, p≤0.001; NHP Questionnaire, p≤0.005; Fatigue Impact Scale, p≤0.005; SCL-90-R, p≤0.05) showed marked differences in psychological function and fatigue in the patients with documented hypopituitarism compared to aged-matched healthy volunteers controls. Conclusion: Based on this data, we postulate that testosterone deficiency in women with hypopituitarism leads to impairment of cognitive function and a marked decrease in their quality of life. These data provide compelling rationale for placebo-controlled, randomized trials of testosterone replacement in women with hypopituitarism.
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